The goal of the proposed development program is to prepare the applicant, Susan L. Mitchell MD for a career as an independent investigator and leader in the field of aging. The award will provide five years of supervised geriatrics health services research with the following specific objectives: 1. to develop expertise in innovative approaches to decision-making for older persons at the end-of-life, 2. to become an expert in outcomes research and resource utilization related to the use medical technologies in frail nursing home patients, and 3. to utilize this expertise in decision-making, health outcomes, and resource utilization to improve the end-of-life care in older persons by influencing clinical management and health care policy. The candidate will achieve these goals through mentored research, coursework, directed readings and educational activities. Dr. Lewis A. Lipsitz, an international leader in geriatrics, Professor of Medicine at Harvard Medical School, Chief of Geriatrics at the Beth Israel Deaconess Medical Center (BIDMC) and Co-Director of the Hebrew Rehabilitation Center for Aged (HRCA) Research and Training Institute will serve as sponsor. Dr. Lipsitz will ensure that Dr. Mitchell will have full advantage of the rich environment of the HRCA, a reknowned center dedicated to gerontological care and research, as well as the Harvard Division on Aging, BIDMC and Harvard School of Public Health. The proposed research is a randomized trial of a feeding tube decision aid for nursing home residents with advanced dementia with a one year follow-up of clinical outcomes and costs. The specific aims of the project are to determine: 1. whether a decision-aid (vs. usual care) improves the decision-making process for long-term tube-feeding, 2. the impact of a decision aid on the substitute decision-makers preferences for tube-feeding, 3. the impact of long-term tube-feeding (vs. no tube-feeding) on clinical outcomes and resource utilization in nursing home residents with advanced dementia. In addition to the proposed project, Dr. Mitchell will achieve her career goals by regularly scheduled meeting with Dr. Lipsitz, as well as members of her advisory panel including; 1. Drs. A. O Connor and A. Mulley - decision-making, health policy, 2. Dr. J. Buchanan - economic evaluation, 3. Dr. M. Gillick - bioethics, 4. J. Weinberg ScD - advanced statitstical methods and 5. Dr. M. Slaven - end-of-life care. Her research activities will be complimented by focussed clinical, educational and administrative activities including the associate directorship of the Harvard Geriatrics Fellowship Program. By the end of the award period the applicant will have the skills, experience and research track record necessary to become an independent investigator and leader in academic geriatrics.